Since the demise of Joan Rivers at an outpatient surgery center last year, there has been increased public awareness of the necessary questions that should be asked and precautions that should be taken to ensure patient safety.
Although most physicians and facilities have implemented best practices, educating the patient about expected standards could help keep systems in check. In the Joan Rivers case, there were many overlooked procedural and clinical aspects of care that were evidenced in qualified public reports on the case. These oversights now serve as reminders to both clinicians and patients of the importance of doing things by the book.
And for pregnant patients needing non-obstetric surgery, there are additional concerns related not only to the baby but also to the physiological changes that occur during pregnancy. For maximum patient safety, perhaps a pregnant patient should avoid any surgical procedure at an ambulatory center, if possible, opting for any necessary procedure to be performed in a hospital setting.
Considerations for All Patients
Credentialing and privileges. Ensure the surgeon is properly credentialed and has privileges to perform the surgery at the selected facility. One would think this is a no-brainer; yet, in the Rivers case, the surgeon did not have privileges to perform any procedure at the outpatient center where her surgery took place.
Proper monitoring of vitals and oxygen levels. In the case of Joan Rivers, the lack of recognition of pre-deteriorating vital signs and intervention was not timely. Vital signs were deteriorating for over 14 minutes on the OR table without any intervention.
Height and weight. An accurate measure of height and weight are an absolute must before any surgery, as this data is what determines the appropriate dosages of anesthesia and any other drugs administered along with anesthesia. Ms River’s body weight was never recorded. Her actual height and weight should have been recorded on the first sheet of the physician's orders before any medications were written and documented in the nursing assessment. In fact, height and weight should have been verified before any medication was administered in particular anesthetics.
Consent. First, having a personal doctor perform a surgery, especially if it isn't their specialty, is risky. In the case of Joan Rivers, the report said that there was no documentation indicating that Ms. Rivers gave consent for her personal physician to conduct a procedure. Patients should be signing both surgical and anesthesia consent before receiving any medications and prior to your surgery.
Emergency protocols. Ambulatory surgery centers should be well-equipped to handling any potential crises, and staff should be competent to manage early any emergency. There was significant delay in the case of Ms Rivers in the initiation of life-saving measures. It's important to know how possible emergencies are handled at ambulatory surgical centers.
Patient engagement. The best protection is an ask-and-answer session between the patient and physician before any scheduled procedure that will take place outside of a hospital. The act of asking questions and receiving answers is key to patient engagement and will ultimately help protect both parties from potential harm. This takes a little homework on the patient's part, so patients should be encouraged to do their research. And if a patient is unsure about what to ask, they should speak with a nurse.
Considerations for Pregnant Patients on next page
Duncan PG ,Pope WD,Cohen MM, Greer N. Fetal risk of anesthesia and surgery during pregnancy. Anesthesiology. 1986;64:790-794.
Radfar F. Laparoscopic surgery in pregnancy: precautions and complications. Available at: http://www.laparoscopyhospital.com/laparoscopic_surgery_in_pregnancy_precautions_and_complications.html. Accessed January 21, 2015.
Stepp K, Falcone T. Laparoscopy in the second trimester of pregnancy. Obstet Gynecol Clin North Am. 2004;31:485-496.
Toledo P. Anesthesia alert: anesthesia for the pregnant patient. Outpatient Surgery. July 2013. Available at: http://www.outpatientsurgery.net/surgical-services/general-anesthesia/anesthesia-alert-anesthesia-for-the-pregnant-patient--07-13. Accessed January 21, 2015.